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JUDITH T. TERRY Town Hall, 53095 Main Road
TOWN CLERK P.O Box 1179
Southold, New York 11971
REGISTRAR OF VITAL STATISTICS �� �`�
MARRIAGE OFFICER Fax (516) 765-1823
4.®t� , �® 7 Telephone (516) 765-1801
OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL PERMIT
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 1867-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner SULLIVAN, WILLIAM J.
Mailing Address 1 P. O. BOX 317
Mailing Address 2
City St Zip NEW SUFFOLK NY 11956-0000
Property Address 1 945 FANNING ROAD
Property Address 2
City St Zip NEW SUFFOLK NY 11956-0000
Owner Telephone No. 516-734-5159
Tax Map No. section 117.00 block 4 lot 26.000
Cross Street NEW SUFFOLK ROAD
Date Of Last Pump Out 0/00/00
Issue Date: 4/06/92 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
OFFICE OF THE TOWN CLERK �FF�
Town of Southold • �0�.; CD ' Application No.18 6 7
Judith T. Terry, Town Clerk . Z �►
Town Hall, 53095 Main Road 7 $10.00 - Residential 1/.
P. O. Box 1179 u' tit Wei .5i $25:00 - Non-Residential
Southold, New York 11971 co'
Telephone
(516)', 7&5-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $ /a .r-
DATE '¢ � ' 711
OWNER
OWNER NAME: W / L LI AA( J S4/LG't VA
OWNER-MAILING ADDRESS: 91-3-.fbNNiArs- C` P ,8o ' 3/ 7
VEw• $affdLK- ,,ttJ. //gd
OWNER PROPERTY ADDRESS: 4-3 AA:l
OWNER TELEPHONE NUMBER: S/C 7.30- _ S7-tel
TAX MAP NO. : Section // 7 Block Lot 6
CROSS STREET:
TYPE OF SYSTEM: . Septic Tank /" New Existing "
Cesspool New Existing
Residential v Non-Residential
DATE OF PREVIOUS PUMP-OUT:
LOCATION MAP: Must be attached hereto before permit may be issued.
(Locate building and system; give north arrow and feet
of distance, approximately, to building and closest road.)
19/V;14;- -
Signature Applicant
RECEIVED
RECEIVED 'BY'. APR• '.!PPTown Clerks •ffice , .
DATE: Southold Town Clerk•
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